Oil Recovered From Saltwater Disposal Wells - Form 5 SWD

Oil Recovered from Saltwater Disposal Wells - Form 5 S.W.D Department of Mineral Resources Oil and Gas Division 600 East Boulevard Dept 474 Bismark, N.D: 58505 to 0614 S.F.N 5752 (03 to 2009)

Checkbox option: Amended

Please Read Instructions Before Filling Out Form.

Please Submit the Original.

Field: Field

Field: County

Field: Operator

Field: Telephone Number

Field: Address

Field: City

Field: State

Field: Zip Code

Well Name and Number & Location (Qtr-Qtr, S-T-R)

Well File Number

Oil In Storage Beginning of Month (Bbls)

Oil Recovered From Skimming Operation (Bbls)

Oil Sold (Bbls)

Oil In Storage End of Month (Bbls)

Field: Purchaser

Field: Transporter

Field: Transportation Method

Field: Comments

I hereby swear or affirm that the information provided is true, complete and correct as determined from all available records.

Field: Date

Field: Signature

Field: Printed Name

Field: Title

Above Signature Witnessed By

Field: Witness Signature

Field: Witness Printed Name

Field: Witness Title

Oil Recovered from Saltwater Disposal Wells - Form 5 S.W.D S.F.N 5752

1. This report is required as a regular monthly report, regardless of the status of operations.

2. This completed report shall be signed and witnessed as provided for in Section 43-02-03-52 of the North Dakota Administrative Code (N.D.A.C).

3. Please refer to Sections 43-02-03-48 and 43-02-03-52 N.D.A.C regarding reporting requirements for oil sold.

4. Wells shall be clearly identified by well name and number, and well file number. The field, county, operator, well name and number, and file number shall coincide with the official records on file with the Commission.

5. Under the column headed "Oil Recovered From Skimming Operation", indicate the recovery for the entire month.

6. Under the column headed "Oil Sold" indicate the amount of oil removed and sold from the disposal well. If a portion of the oil was taken from the well by anyone other than the parties listed on the approved Authorization to Purchase and Transport Oil from Lease - Form 8 (S.F.N 5698) on file with the Commission, a proper notation shall be made in the comments section.

7. All volumes shall be reported as barrels (42 gallons), corrected to 14.73 psia and 60 degrees F. All volumes shall be rounded to the nearest full barrel.

8. If this is an amended report, the amended volumes shall be clearly indicated.

9. The original of this report shall be filed with the Department of Mineral Resources, Oil and Gas Division, 600 East Boulevard, Dept. 474, Bismarck, N.D 58505 to 0614 on or before the first day of the second succeeding month. Wells for Which This Report Is Not Received May Be Shut-In.